Fixing the flat: What to know about flat spots on infants' heads

What to know about plagiocephaly and the shape of your infant's head

MEEGAN M. REID / scripps newspapers
Maxwell Rubenstein, who began to develop a flat spot on the back of his head when he was a young infant, wears a helmet to mold his head into a rounder shape. Helmets can be prescribed to treat more serious cases of plagiocephaly, or flat-head syndrome.$RETURN$$RETURN$

MEEGAN M. REID / scripps newspapers
Maxwell Rubenstein has been wearing a helmet to treat a condition called plagiocephaly since February. Helmets to treat flat spots on babies’ heads have been used since the 1970s, when a Seattle-area physician took a cue from Native Americans who used devices to mold their babies’ heads as part of a cultural practice. Since then, they have been used to make babies’ heads more symmetrical.$RETURN$$RETURN$

Pediatric physical therapist Margaret Royce works with Maxwel Rubenstein at Harrison Medical Center. Maxwell has worn a helmet since February to mold his head to a more rounder shape after a flat spot developed when he was a young infant. (MEEGAN M. REID / KITSAP SUN)$RETURN$$RETURN$

MEEGAN M. REID / scripps newspapers
Pediatric physical therapist Margaret Royce works with Maxwell Rubenstein at Harrison Medical Center in Silverdale, Wash.. Maxwell receives physical therapy for a condition called torticollis, which is a contraction of muscles in the neck. Babies who have torticollis are at risk of developing flat spots because of the limited range of motion when it comes to moving their head.$RETURN$$RETURN$

MEEGAN M. REID / Scripps Newspapers
Pediatric physical therapist Margaret Royce works with Maxwell Rubenstein at Harrison Medical Center in Silverdale, Wash. Maxwell receives physical therapy for a condition called torticollis, which is a muscle contraction of the neck. It is a common cause of plagiocephaly, or flat-head syndrome, in babies.$RETURN$$RETURN$
MEEGAN M. REID / scripps newspapers
Pediatric physical therapist Margaret Royce works with Maxwell Rubenstein at Harrison Medical Center in Silverdale, Wash. Maxwell receives physical therapy for a condition called torticollis, which is a muscle contraction of the neck. It is a common cause of plagiocephaly, or flat-head syndrome, in babies.

BREMERTON, Wash. — When my son Maxwell turned 3 months old, I began to notice that his head — a perfectly round, adorable orb when he was born — was taking on an odd shape.

On one side, a bulge was developing. On another, it was flat. I figured it was temporary and would resolve itself.

But at his next well-baby appointment the pediatrician examined his head and diagnosed something called “plagiocephaly.” She had some urgency in her voice when she instructed me that he was absolutely not to be on his back unless he was sleeping.

Plagiocephaly is the medical term for what is more casually called “flat head syndrome.” Health practitioners say it’s been on the rise since the early 1990s, when pediatricians began urging parents to lay their babies down to sleep on their backs to prevent Sudden Infant Death Syndrome.

While the so-called “Back to Sleep” campaign has dramatically reduced the number of deaths from SIDS, it has also increased the number of babies with misshapen heads. Because babies are spending more time on their backs, they are spending more time with their heads positioned in one place. Any prolonged pressure on one spot can flatten the malleable bones of the skull or cause misalignment.

Doctors and health practitioners view the “Back to Sleep” campaign as a success. “It’s important to have babies sleep on their back,” said Darcy King, an Advanced Registered Nurse Practitioner at Seattle Children’s Hospital.

Practitioners stress the importance of tummy time as a counter to the time babies spend sleeping on their backs. But speaking as a new parent, it’s easy for it to get pushed down the “to-do” list.

CAUSES OF PLAGIOCEPHALY

A trip to Seattle Children’s Hospital after a referral revealed that Maxwell’s flat spot was caused by another condition, torticollis — a muscle contraction in the neck that causes the head to tilt. The limited range of motion of his neck meant his head gravitated to one position while he was on his back.

Certain babies are prone to plagiocephaly. In addition to those born with torticollis, King, who works in the Craniofacial Center at Seattle Children’s Hospital and assessed Maxwell, said that multiples (twins or triplets) can be at risk. Premature babies or newborns who spent a lot of time on their backs in neonatal care can develop it, along with children who are slower to reach major gross motor milestones, like rolling over, which help them get off their backs.

Physical therapists and others who work with babies with plagiocephaly say that the popularity of carry-it-everywhere car seats has also led to the increase in cases.

“It’s not just when they are sleeping” that babies are often on their backs, said Lauren Blacken, a certified orthotist at the Hanger Clinic in Bremerton, which crafts helmets that mold the heads of babies suffering from plagiocephaly. “Now, (car seats) go from the car, to the grocery store, back to the car.”

OUR HELMET JOURNEY

The treatment for Maxwell’s flat spot began with what practitioners called “repositioning.” In addition to keeping him off his back during his awake hours, we tried to move his head off the flat spot when he was sleeping. We were more cognizant about switching the way he faced when he was bottle-fed. We did the same thing in the crib at night, laying his head on the opposite side from the night before.

We put a new focus on tummy time. Before the diagnosis, I figured five minutes here and there a few times a day was enough for a baby who loudly protested when I put him in that position. The physical therapist who began treating Maxwell for torticollis said to double or triple what was recommended.

While seeing some initial positive results with the repositioning over four months, by the time he hit 8 months old, we faced a decision: the “conservative” course of treatment of repositioning was not getting rid of the flat spot.

The next step was a helmet, or a “cranial remodeling orthosis.” We were advised that if we were going to go that route, we would want to begin treatment to get the maximum results before the bones in his skull began to fuse.

“When those joints fuse, we can no longer affect the shape of the skull,” said Blacken, with the Hanger Clinic.

We were instructed that the helmet would have to be worn 23 hours a day.

Both King and Blacken assured us that the helmet was safe. The first helmet was actually developed by a doctor at Seattle Children’s Hospital named Sterling Clarren in the 1970s. Clarren noted in an article he wrote in the Journal of Prosthetics and Orthotics in 2004 that Native Americans in the Pacific Northwest used helmets to deliberately alter their babies’ head shape with no harm. So, he thought, why not use them to make the heads of babies suffering from plagiocephaly more symmetric.

The custom-molded helmet works by compacting the high spots and redirecting the skull’s growth to the low spots. The helmets are regulated by the Food and Drug Administration and are created in a facility with special approval. The helmet is customized to the baby’s head after the orthotist takes a 3-D scan.

As parents, our first concern was that Maxwell would be uncomfortable wearing it. Secondary to that was accepting that fact the helmet would serve as a barrier to our kisses and affection during the treatment, which was estimated to be about four months.

Both King and Blacken assured us that babies don’t experience discomfort from the helmet. King compared it to a diaper, something they get used to wearing.

THE ROAD TO SUCCESS

Three months into the treatment, Maxwell’s head is rounding out and we’re seeing success. While the decision to put him into a helmet seemed emotional at the time, if we had to make it again, it’d be a no-brainer.

King said it’s common for families to experience a range of feelings as they go through the process of diagnosis and treatment of plagiocephaly. Once learning about its causes, as a mom, I did wish I could have gone back in time and upped the amount of time he was on his tummy, taken him out of his swing or turned his head to the other side as he slept.

King sums the feeling up well: “One mom described it as their first mommy fail,” she said. But, she added, “I try to explain that the problem is multifactoral. It’s not something that was caused by the parents and how they cared for their child.”

Still, it’s a problem that I caution new parents I come across about. Though pediatricians tell parents tummy time is important, they may, like me, forget to prioritize it as they’re working through feeding issues, developing a sleep schedule and juggling all the new things that come with mothering a newborn.

King advises monitoring infants’ head shape and to take note if they seem to prefer looking to one side or the other, which could be signs of torticollis. If a flat spot develops, try to keep them off it as much as possible and address the problem with a pediatrician.

“Many kids do get better over time with repositioning,” she said. “If it doesn’t get better over time, seek an evaluation.”